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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701175
Report Date: 07/02/2026
Date Signed: 07/02/2026 02:00:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2026 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20260211102526
FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIIFACILITY NUMBER:
342701175
ADMINISTRATOR:TAYLOR, MARIEFACILITY TYPE:
740
ADDRESS:7695 RIVER VILLAGE DRTELEPHONE:
(916) 400-4098
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
07/02/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gloria Clarke-Daley and Diana GarciaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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The Administrator is not present at the facility for a sufficient amount of time.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Avelina Martinez and Sulma Lopez arrived at the facility unannounced on July 02, 2026, at 9:30 AM to deliver complaint findings, LPAs met with Gloria Clarke-Daley and Diana Garcia, and explained the purpose of the visit.

Throughout the course of the investigation, LPAs conducted interviews, facility inspections, and file reviews. During a file review, it was learned that resident files were not maintained. Required documents were not complete, and two reappraisals have not been completed. Additionally, the facility printer/copy machine is not in good repair, and facility staff member is not able to print out July 2026, Medication Administration Records (MAR). As of July 02, 2026-9:30 AM , the Administrator has not delivered MARs to the facility. In addition, the Administrator was not present at the following Community Care Licensing inspection visits: February 20, 2026, July 02, 2026, and July 30, 2025.

report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20260211102526
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN LEGACY ELDERLY CARE III
FACILITY NUMBER: 342701175
VISIT DATE: 07/02/2026
NARRATIVE
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As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D page, per Title 22 Regulations.

An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2026 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20260211102526

FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIIFACILITY NUMBER:
342701175
ADMINISTRATOR:TAYLOR, MARIEFACILITY TYPE:
740
ADDRESS:7695 RIVER VILLAGE DRTELEPHONE:
(916) 400-4098
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
07/02/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gloria Clarke-Daley and Diana GarciaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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The facility allowed excluded individuals to work in the facility.
Staff are forging resident documents.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Avelina Martinez and Sulma Lopez arrived at the facility unannounced on July 02, 2026, at 9:30 AM to deliver complaint findings, LPAs met with Gloria Clarke-Daley and Diana Garcia, and explained the purpose of the visit.

Throughout the course of the investigation, LPAs conducted interviews, facility inspection, and file review. Based on this investigation, two out of six LIC 602 Medical Assessment for Residential Care Facilities for the Elderly (LIC602) were not complete. Facility documents did not indicate that they have been forged. During one staff interview, staff 1 (S1) reported that staff are not forging facility documents. Six out of seven interviews reported they have not witnessed excluded individuals in the facility. One out of seven residents was not able to provide accurate information regarding excluded individuals.

report continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20260211102526
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN LEGACY ELDERLY CARE III
FACILITY NUMBER: 342701175
VISIT DATE: 07/02/2026
NARRATIVE
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Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260211102526
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE III
FACILITY NUMBER: 342701175
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2026
Section Cited
CCR
87405(a)
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87405(a) Administrator - Qualifications and Duties:...administrator...shall be on the premises a sufficient number of hours to permit adequate attention to the
management and administration of the facility...This requirement was not met as evidence by:
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The Administrator shall be present in the facility 40 hours per week starting July 02, 2026. LIC 500 Personnel report shall be emailed to LPA Martinez by July 17, 2026 by 5:00 PM. Licensee will appoint a new administrator by POC date July 17, 2026.
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 based on observation, interviews, and file reviews, the Licensee did not ensure that the admin was present at the facility a sufficient amount of hours to complete management/administration duties. This posed a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5